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Theft_Report_Form_1_

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					                         Tradewise Insurance Services Ltd.
                         Unit 1, Northgate Business Centre, Crown Road, Enfield EN1 1TH
                                       Tel 020 8350 4020 Fax 020 8364 7858


                                           FIRE / THEFT REPORT FORM

Ensure all sections of this form are completed fully. Dashes or N/A are not acceptable. Also note that any attempt to
defraud Underwriters will result in criminal prosecution.

SECTION ONE – POLICYHOLDER

Name…………………………………………………..Date of Birth……………….. VAT Registered……………...………
Trading Title……………………………………………………………………………………………………………………..
Private Address…………………………………………………………………………………………………………………
Business Address……………………………………………………………………………….…………………………….…
F-T Occupation…………………………………………………P-T Occupation……………………………………………..
Private Tel………………………………….…Business Tel…………………………….MobileTel………………………….
Policy Number………………….....Broker…………..…..………Policy Expiry……..…..…………Cover………...……….

SECTION TWO – LAST PERMITTED DRIVERS DETAILS (A CLEAR PHOTOCOPY OF THE LAST DRIVERS
LICENCE MUST ACCOMPANY THIS FORM. DELAYS WILL OCCUR IF IT IS OMITTED)

Name………………………………………………………………...Date of Birth…………………………………………….
Address…………………………………………………………………………………………….……………………………..
F-T Occupation……………………………………………………..P-T Occupation……………………………………….
Private Tel……………………………Business Tel…..……………….…………..Mobile Tel….……………….…………
Type of Licence………………………Licence Number…………...……………...Date Test Passed…………..……………
Relationship to Policyholder……………………………………………………………………………………………………
Please give details of previous convictions including non-motoring convictions (which are not spent) and convictions
pending. If none, state none.

 Date of Conviction               Conviction Type and Circumstances                        Fine / Sentence




Give details of any physical defects or infirmities ……………………………………………………………………………
Has Insurance ever been cancelled or refused?……………………………………………………………………………….
Is driver insured in respect of his own vehicle? If yes, give insurers details. ……………………………………………….
…………………………………………………………………………………………………………………………………….
Please give details of previous accidents/claims/losses. If none, state none.

 Date of Incident                 Circumstances                                            Cost
SECTION THREE – USAGE OF VEHICLE

State exact use of the vehicle prior to the Incident. The words BUSINESS/PLEASURE are not sufficient.
…………………………………………………………………………………………………………………………………….
State exact details of the journey. Travelling from………………………………..to…..……………………………………
Was the vehicle being used in connection with the occupation of the Policyholder / driver? ……………………………..
…………………………………………………………………………………………………………………………………….
Were any goods being carried? If yes, give particulars together with details of the Goods in Transit Insurers …….…...
…………………………………………………………………………………………………………………………………….

SECTION FOUR – PARTICULARS OF VEHICLE / OWNERSHIP

Vehicle Make/Model…………………………Registration Number………………..Date of Registration...……………….
Engine Size…………………...…..Colour……………………Mileage………………Current Value……………………….
Date of Purchase……………………………..Price Paid……………………………..Is vehicle left hand drive?…………..
Does the vehicle have a current MOT?……………………………………..Expiry Date……………………………………
Does the vehicle have a current Road Fund Licence?……………………..Expiry Date.…………………………………...
Has the vehicle been modified? If yes, give full details ……………………………………………………………………….
…………………………………………………………………………………………………………………………………….
Was there any pre-incident damage? If yes, give full details …………………………...……………………………………
What was the general pre-incident condition of the vehicle …………………………...…………………………………….
Give details of any recent repair/maintenance work on the vehicle…….………………...…………………………………
Please state details of registered owner of this vehicle if not registered in the name of the Policyholder.
Name………………………………………….Relationship to Policyholder………………………………………………….
Address…………………………………………………………………………………………………………………………...
Telephone Number………………………………………………………………………………………………………………
Give details of any HP company interest in the vehicle………………………………………………………………………
……………………………………………………………………………………………………………………………………
If customers vehicle give time and date that it came into your possession…………………………………………………..
For what purpose was the vehicle in your possession?………………………………………………………………………..
If a sale vehicle, where was the sale advertised? Give details of contact names and numbers ...…………………………..
…………………………………………………………………………………………………………………………………….
When were you due to hand back the vehicle?………………………………………………………………………………..
What work had been carried out on the vehicle (supply documentation)?...………………………………………………..
…………………………………………………………………………………………………………………………………….
If the vehicle is owned by the Policyholder but not yet registered (i.e. stock vehicle), please clarify the following.
Who paid for the vehicle (Insured/Named Driver/Other)?…………………………………………………………………...
Method of Payment, (i.e.cash, cheque)…………………………………………………………………………………………
Who was the vehicle purchased from?…………………………………………………………………………………………
What is their relationship to the vendor (if any)? …………………………………………………………………………….
If log book is not in the vendors name state reason if known ……………….……………………………………………….
…………………………………………………………………………………………………………………………………….

SECTION FIVE – DETAILS OF THEFT / FIRE

Date………………………………………………………….…Time…………………………………………………………...
Exact Location of Loss, including distance from premises if applicable……………………………….……………………
…………………………………………………………………………………………………………………………………….
If incident occurred on premises, state type …………………………………………………………………………………..
Who owns the premises?………………………………………………………………………………………………………..
How long had the vehicle been parked at the location of loss?……………………………………………………………….
For what purpose was the vehicle parked there?……………………………………………………………………………..
When was the last time you saw / drove the vehicle?…………………………………………………………………………
When did you intend to collect the vehicle / drive it again?…………………………………………………………………..
When and by whom was the loss discovered?…..……………………………………………………………………………..
Were all doors/windows locked and in working order?………………………………………………………………………
Who had the keys at the time of the Loss?…………………………………………………………………………………….
Were the keys in the ignition?…………………………………………………………………………………………………..
Was the vehicle fitted with an alarm/immobilizer? …………………………………………………………………………..
Was it engaged?………………………………………………………………………………………………………………….
State Make and Model (please supply copy of installation certificate) .…………………………………………………….
State the circumstances of the Loss ……………………………………………………………………………………………
…………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………
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……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
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Please state names and addresses of any other person having knowledge of the circumstances of the loss.
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………….
Do you have any suspicions as to who could have perpetrated the loss and have you advised the police of your
suspicions?
……………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………….
Was the vehicle involved in an accident whilst it was stolen? If yes, give details …………………………………………..
…………………………………………………………………………………………………………………………………….

SECTION SIX - RECOVERY OF VEHICLE

State fully who discovered the vehicle and arrange for its recovery. Include all relevant information.
………………………………………………………………………………………………………………………………….…
………………………………………………………………………………………………………………………………….…
…………………………………………………………………………………………………………………………………….
Describe type and location of damage (enclose two competitive repair estimates where possible)
………………………………………………………………………………….…………………………………………………
…………………………………………………………………………………………………………………………………….
What is the estimated cost of repair?…………………………………………………………………………………………..
Where and when can the vehicle be inspected?……………………………………………………………………………….
Name and Address of Repairer………………………………………………………………………………………………...
Telephone………………………………………………………………………………………………………………………...

SECTION SEVEN – POLICE DETAILS

Name and Address of where the Theft was reported…………………………………………………………………………
…………………………………………………………………………………………………………………………………….
Date and time reported and by whom………………………………………………………………………………………….
Crime Reference…………………………………………………………………………………………………………………
Have any suspects been apprehended………………………………………………………………………………………….
SECTION EIGHT – ADDITIONAL INFORMATION

Please provide any additional information which you feel may be helpful to us in dealing with your claim.

……………………………………………………………………………………………………………………………………
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……………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………….


WARNING – INSURERS MAINTAIN MOTOR INSURANCE ANTI FRAUD AND THEFT REGISTERS AND
EXCHANGE INFORMATION TO PREVENT FRAUDULANT CLAIMS. WE REFER YOU TO THE DATA
PROTECTION NOTICE ON PAGE 11 OF THE POLICY WORDING BOOKLET

REMINDER

If the vehicle has not been recovered or appears to be damaged beyond repair please ensure you provide the following
original items.

Evidence of involvement in Motor Trade ( e.g. copy of trading accounts )
Vehicle Registration Document
Current and Past MOT Certificates
Purchase Receipt or copy bank statement
Servicing Documents
Keys
Vehicle Photographs
Plating Certificate (if applicable)

SECTION NINE – DECLARATION

I hereby declare that all particulars on this claim form are true in every respect. I am aware that any attempt to
defraud WILL result in prosecution being taken against me. I hereby authorise Tradewise Underwriting Agencies or
their nominated legal representatives to deal with any third party claim as they see fit. I also authorise release of my
DVLA records and police records and agree to co-operate with any investigation that is necessary to progress my
claim.

Signature of last person in charge of vehicle……………………………………………Date………………………………..

Signature of Policyholder…………………………………………………………………Date……………………………….

Signature of Witness………………………………………………………………………Date……………………………….

PLEASE CHECK THROUGH THE FORM AND CHECK THAT YOU HAVE ANSWERED ALL THE
QUESTIONS AS FULLY AND ACCURATE AS POSSIBLE.
MANDATE FOR RELEASE OF INFORMATION UNDER DATE SUBJECT ACCESS PROVISIONS OF THE
DATA PROTECTION ACT 1984 ( SECTION 21 (1) AND (2) )



COMPANY DETAILS

NAME AND ADDRESS OF COMPANY                   TRADEWISE INSURANCE SERVICES LTD
                                              UNIT 1, NORTHGATE BUSINESS CENTRE
                                              CROWN ROAD
                                              ENFIELD
                                              EN1 1TH

ACCOUNT NUMBER …………………………….. REFERENCE NUMBER …………………………………………….

THE INFORMATION IS REQUIRED FOR THE FOLLOWING PURPOSE(S) ………………………………………...
…………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………….

DRIVER DETAILS

I authorise the Driver and Vehicle Licensing Agency (DVLA) to supply any information with the exception of any
medical information that may be held on its driver computer record, relating to myself and my driving entitlement
past and present including any valid endorsements, disqualifications etc. (within the meaning of the Road Traffic
Offenders Act 1988), to the company named above. I request that the information be sent to (delete as appropriate)

   MYSELF AT THE ADDRESS BELOW
   TO THE COMPANY

FIRST NAME(S)
……………………………………………………………………………………………………………….……………………
SURNAME
…………………………………………………………………………………………………………………………………….

DATE OF BIRTH ………………………… DRIVER NUMBER …………………………………………………………...

CURRENT ADDRESS
…………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………….
………………………………………………………………………………….. POSTCODE ………………………………...

PREVIOUS ADDRESS
…………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………….
………………………………………………………………………………….. POSTCODE ………………………………...

Important Note: If your current address is not shown on your driving licence you should return it to the DVLA
immediately, so that a new one showing the correct address can be issued. Failure to notify changes of name and
address is an offence, which could lead to a fine of up to £1000.00.

SIGNED …………………………………………………….. DATE ………………………………………………………….

n.b. Any request for information will not be processed later than three months after the date of signature.

				
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posted:4/11/2012
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